9809-025 (SFD)LICENSED CONTRACTOR DECLARATION_
I -4M*T _
Thereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and r
Piofessionals Code, and my License is in full force and effept
License # Lic. Class Exp. Date
710743 h A !. 4-) rU
-,Cate Signature of Contractor /Vr!
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) I, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered for,,
sale (Sec. 7044, Business & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project -„(Sec. 7044 "-Business & Professionals
Code).
() I am exempt under Section ' B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
( ) I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
(y I have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
,Carrier - Policy No.
QIGINA
(This section need not be completed if the permit valuation is for $100.00 or less).
() I certify that in the performance of the work for which this permit is issued,
1 -,shall not employ any person in any manner so as to become subject to the
workers`' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of Section 700 of the Labor
Zode, I sha I f rt i h comply with t, o e prov Ions.
te:Applicant `
Warning: Failure to secure,Workers' Compensation. coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permlt subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant'to
any permit issued as a result of this applicaton agrees to, & shall;' indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days' from date of issuance of such.:,
permit, or cessation of work for 180 days will subject permit to cancellation
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon,
th�/e,above-mentioned property for inspection pu oses.
ySignature•(Owne0Agent) '-�� ^hi Date L
- Y i
PERMIT# . . CONTROL#
BUILDING PERMIT
DATE / / VALUATION 5279.'68 So LOT -2 TRACT -8121
ADDRESS J013 SIfE
APN 769L560424
OWNER
CONTRACTOR DESIGNER ENGINEER
s4
.tflxi. PACp1r`ntC
"APP* AL PACIFIC C1�.S INC -
a1cJ(J �1�1C .r�%t Itlii $erV`T3 02013 ,
4100 MAC Atci`id.C.1R BLVD n2(r0
N1✓WW'ACT 1; )3k( ,-H CA '426960
NEWPORT B Afli CA 92660
(941?)622.-8400 CBL>`+` 1-50.3
ti
USE OF PERMIT
SINGLE PAKIL.•Y iJ` E L ING
SM -PLAN 3AR, LOT 42 #; -Iyl f2A, IT DOES 140i TINCLUDE ALOCK WALL:, _
Oil POOL. KAigt CHW K. FEE RkDt;JC,0) BY 75"N. hOR MV.LT1.PJ,8 VSUAM,''
y
OF S!liME PL AN 'i YPt.
Ci; QOM C0,1NISTRUICT ION 3j400.00SF
TIORO*114 IO 268.00 Sk`
0ARAO&CARPORT 589.00 v
ESTMATED CLXrf OF CONST:1:JMUIN
2",9,96 181.?
PERMIT Ii Fr SUMMARY
CONS'9 f2 ICTi:ON EF, 101-600-4.19-000 g1 X61+.
PLAN CR CKs, FW -39(11.0(10-439-1-418
NeF�t';m.4ici� .rmt 101-000-42a-000 4�i4, Ci
Ej`� ,"t atIOAL FIM , 10H)004120_000 $188.28
PE.UWTNO FFX, 101-000-4.19-000 1.80,50
,si'RO NO MOT.'ION FEE - IMS ID 1,01 -MO -241
ta12t ANQ F11-16 101-000-423-(100 520.00
INF RA:>'i RUC`•'iME FFE 225-000-443-312 KOM.(*
ART IN PUBLIC PLAC013 - 0 3i):� 701-0{60-25S•-000 P+449.92
t
� J -.''CAL C( N"uZr VC1rJQN AND PLAN CHECK
LESS P. R r ES
$0.00
•
rSEP 2.91998' `a't) At, 9�E�a1 T.0 ��'14,VS :a�UF NI OW
.Y .. 4
RECEIPT"
DATE
I BY6.22
DAT FINALED
INSPECTOR
/I
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APIA,' /ALS
MECHANICAL APPROVALS
Set Backs
d- ��
Underground Ducts
Forms & Footings
_ _
Ducts
SlOb Grade
`�- lQ (� _
Return Air
Steel
Combustion Air
Roof Deck
� 16, -
Exhaust Fans
O.K to Wrap
Framing
e_'1AJ Of_ `y ��
F.A.U.
Compressor
Insulation
CGG
Vents
/ �O�
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
G4�
Drywall -Int. lath
Final
Final
0 -,22= _ _
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric s'
Underground Plbg. Test 1
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
,Sewer Lateral
Pool Cover
Sewer Connection
r. q�j oQ �i+
Encapsulation
Gas Piping
Gas
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS"/
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
c
Final
Utility Notice (Perm)
Desert Sands Unified School District
47-950 Dune Palms Road
Notice: La Quinta, CA 92253
Document Cannot Be Duplicated 760-771-8515 ;
CERTIFICATE OF COMPLIANCE.
Date 9/17/98 APN # . 769-560-024
No. 17758 Jurisdiction La' Quinta
Owner NameCapital Pacific Holdings, Inc. Permit #
No. 79-980 Street Tangelo Log #
City La Quinta Zip 92253 Study Area
Tract # 24890-3 Lot # 24 Square Footage 1
Type of Development Single Family- Residence No. of Units 1
Comments
Under grandfather agreement - 3,400 sq. ft. (The Citrus Course)
At the present time, the Desert Sands Unified School' District does not collect fees on garages/carports, covered
patios/walkways, residential additions under 500 square feet, detached accessory structures or replacement mobilehomes.
It has been'determined the above-named owner is, exempt from paying school fees at this time due to the following
reason:
Under Mitigation Agreement
EXEMPTION NOT APPLICABLE
This certifies that school facility fees imposed pursuant to Mitigation Agreement in the amount of _
r'4 F
628.00 X 1 or $ 628.00 the property listed above and that',,building
permits and/or Certificates of Occupancy for this square footage in this proposed project ma'y,;.now be issued'
Fees Paid By CC/Wells Fargo & Co./Manuel Telepho ,564- 447
Name on the check,'-,_
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Juanita Green
Signature
Payment Received $628.00
Check No. 0643036924
NOTICE: Pursuant of Assembly Ifill 3081 (CHAP 549, STATS. 1996) this will serve to notify you that the 90 -day approval period in which you may protest the fees or other payment identified
above will begin to run from the date on which the building or installation permit for this project is sssued or on which they are paid to the District(s) or to another public entity authorized to
collect them on the District('s)(s') behalf, whichever is earlier.
Collector: Attach a copy of county or city plan check application form to district copy for all waivers.
Embossed Original- Building Dept./Applicant Copy-.Applicant/Receipt Copy - Accounting